What medication is recommended to start in the setting of hypertension urgency?

Management of Hypertensive Urgency

In hypertensive urgency, oral antihypertensive therapy is recommended as the preferred treatment approach, with reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable. 1

Definition and Distinction

Hypertensive urgency is defined as severe blood pressure elevation (>180/120 mmHg) in otherwise stable patients without acute or impending change in target organ damage or dysfunction. This is distinct from hypertensive emergency, which involves evidence of new or worsening target organ damage and requires immediate IV therapy.

First-Line Treatment Approach

• Oral medication is the preferred treatment method for hypertensive urgency
• No immediate reduction in BP in the emergency department or hospitalization is indicated
• Treatment involves reinstitution or intensification of antihypertensive drug therapy

Medication Selection

The following oral agents can be considered for hypertensive urgency:

• ACE inhibitors or ARBs (first-line)
• Dihydropyridine calcium channel blockers (first-line)
• Beta-blockers (particularly useful if tachycardia is present)

Medications to Avoid

• Non-dihydropyridine calcium channel blockers
• Immediate-release nifedipine
• Hydralazine (unpredictable response and prolonged duration of action make it undesirable) 2, 3
• Sodium nitroprusside (extremely toxic and should be avoided) 2

Blood Pressure Targets

• Target BP <140/90 mmHg for most patients
• Controlled reduction over 24-48 hours is appropriate
• Avoid excessive or rapid BP reduction which can lead to hypoperfusion

Monitoring and Follow-up

• Close monitoring of BP is recommended
• Home BP monitoring twice daily if feasible
• Follow-up within 24-48 hours to assess response to therapy

Important Considerations

• Many patients with hypertensive urgency have withdrawn from or are non-compliant with antihypertensive therapy 1
• Patients should not be referred to the emergency department for hypertensive urgency alone
• Elderly patients may require more gradual blood pressure reduction to avoid hypoperfusion

Pitfalls to Avoid

1. Confusing hypertensive urgency with hypertensive emergency (which requires IV therapy)
2. Lowering blood pressure too rapidly, which can cause end-organ hypoperfusion
3. Using parenteral medications when oral therapy is appropriate
4. Failing to address medication adherence issues
5. Not arranging appropriate follow-up

Special Situations

For patients transitioning from IV to oral therapy (after a hypertensive emergency has been controlled):

• For patients who received labetalol IV, the recommended initial oral dose is 200 mg, followed in 6-12 hours by an additional dose of 200 or 400 mg 4
• For patients who received enalaprilat IV, the recommended initial oral dose of enalapril is 5 mg once daily for patients with creatinine clearance >30 mL/min and 2.5 mg once daily for patients with creatinine clearance ≤30 mL/min 5

Hypertensive urgency is a clinical situation requiring prompt but not immediate intervention, with oral medications being the mainstay of therapy and careful attention to avoiding excessive blood pressure reduction.